Pituitary adenoma with oculomotor cistern extension: membranous anatomy and clinical application.

BACKGROUND: The anatomical basis of pituitary adenomas (PAs) with oculomotor cistern (OC) extension as a growth corridor is overlooked in the literature. In this paper, the authors use the technique of epoxy sheet plastination to study the membranous structure of the OC and validate the results by retrospective analysis of patients with OC extension. METHODS: Eighteen specimens were used to study the membranous anatomy surrounding the OC using the epoxy sheet plastination technique. Thirty-four patients with OC extension were retrospectively reviewed. RESULTS: The OC consisted of two thin membranous layers. The inner layer was extended by the arachnoid layer from the posterior fossa, and the lateral layer consisted of the dura mater sinking from the roof of the cavernous sinus. The oculomotor nerve is more likely to displace with a superolateral trajectory due to the weakness of the posterior dura and the relatively large space in the medial and posterior trajectories, which is consistent with the intraoperative observations. Among the anatomical factors that affect the PA by OC extension, we found that the relative position of the internal carotid artery (ICA) and posterior clinoid process may lead to the narrowing of the OC. Of 34 cases, 28 patients achieved total resection. Among 24 preoperative patients with oculomotor nerve palsy, 16 cases were relieved to varying degrees postoperatively. There was no ICA injury or severe intracranial infection found in any of the patients. CONCLUSIONS: Extension into the OC is influenced by two anatomical factors: a weak point in the dura in the posterior OC and a potential space beyond this region of the dura. Meticulous knowledge of the membranous anatomy in endoscopic endonasal surgery is required to safely and effectively resect PA with OC extension.

Perisellar Tumor Coexisting with Unruptured Cerebral Aneurysm: Single-Stage or Staged Surgery?

OBJECTIVE: The coexistence of perisellar tumors and intracranial aneurysms was previously considered a rare phenomenon. In this study, we introduce our experience with surgical strategies for the treatment of such coexisting pathologies. METHODS: This retrospective study reviews the medical records and intraoperative videos of patients with coexisting pathologies of perisellar tumors and aneurysms from Nov 2017 to Oct 2022. RESULTS: Our study involved 20 patients, including 9 males and 11 females. Three patients selected the single-stage endoscopic endonasal approach (EEA), including one with a type of MP trigeminal schwannoma with an anterior communicating aneurysm, 1 with a pleomorphic xanthoastrocytoma with a left internal carotid artery paraclinoid aneurysm, and 1 with a recurrent pituitary adenoma with a right internal carotid artery paraclinoid aneurysm. Thirteen patients chose tumor resection first through the EEA with embolization or aneurysm conservation. There were also 2 patients with irregularly shaped aneurysms who chose embolization before tumor resection. All tumors were completely removed, with only a few patients experiencing recurrence and postoperative complications, and the follow-up of the aneurysms was also stable. There were also 2 patients who chose conservative management for both tumors and aneurysms, but unfortunately, one of them suffered from aneurysm rupture and eventually died. No cerebrospinal fluid rhinorrhea, severe intracranial infection, or surgical-related hemorrhage was found in any patients. CONCLUSIONS: Staged surgery or conservative treatment for aneurysms can be considered a safe and effective strategy for the treatment of coexisting pathologies. However, in very selected cases, the single-stage EEA can be used as part of a comprehensive treatment for such coexisting pathologies.

Endoscopic Endonasal Approach for Trigeminal Schwannomas: Tailored Approaches Based on Lesion Traits.

OBJECTIVES: To describe four endoscopic endonasal subapproaches, namely, the trans-lamina papyracea, trans-prelacrimal recess, trans-Meckel's cave, and transclival approaches for trigeminal schwannomas (TSs). METHODS: This retrospective study reviewed the medical records and intraoperative videos of 38 patients with TSs who underwent endoscopic endonasal approach (EEA) between Jan 2013 and Dec 2021. RESULTS: According to Jeong's classification, for TS equally in middle and posterior fossae (MP), a purely trans-Meckel's cave approach was carried out in 2 cases, and a combined transclival approach was carried out in 4 cases. The four tumors that involved infratemporal fossa (two E3, one mE3, and one Mpe3) were performed via a trans-prelacrimal recess approach, and type Mpe3 was also assisted by the trans-Meckel's cave approach. One patient with type E1 was treated with a trans-lamina papyracea approach. The other 27 cases, including type M, Mp, ME2, and MpE2, were all removed by a purely trans-Meckel's cave approach. Thirty-six patients (97.4%) received total resection under a purely EEA. The functional abilities and preoperative symptoms of 31 patients (88.6%) improved. Eight (21.1%) patients experienced permanent neurological function deficits. Postoperative cerebrospinal fluid and intraoperative internal carotid artery injury occurred in 1 (2.6%) patient. CONCLUSION: According to the specific endoscopic endonasal subapproaches corresponding to the different TS locations, satisfactory results can be obtained for most types of tumors. It represents an effective alternative to the open transcranial approach and can also be properly used in most types of TS with experienced hands. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2564-2571, 2023.

Enhancement of hypothalamic STAT3 acetylation by nuclear receptor Nur77 dictates leptin sensitivity.

Leptin, an anorexigenic hormone in the hypothalamus, suppresses food intake and increases energy expenditure. Failure to respond to leptin will lead to obesity. Here, we discovered that nuclear receptor Nur77 expression is lower in the hypothalamus of obese mice compared with normal mice. Injection of leptin results in significant reduction in body weight in wild-type mice but not in Nur77 knockout (KO) littermates or mice with specific Nur77 knockdown in the hypothalamus. Hypothalamic Nur77 not only participates in leptin central control of food intake but also expands leptin's reach to liver and adipose tissues to regulate lipid metabolism. Nur77 facilitates signal transducer and activator of transcription 3 (STAT3) acetylation by recruiting acetylase p300 and disassociating deacetylase histone deacetylase 1 (HDAC1) to enhance the transcriptional activity of STAT3 and consequently modulates the expression of downstream gene Pomc in the hypothalamus. Nur77 deficiency compromises response to leptin in mice fed a high-fat diet. Severe leptin resistance in Nur77 KO mice with increased appetite, lower energy expenditure, and hyperleptinemia contributes to aging-induced obesity. Our study opens a new avenue for regulating metabolism with Nur77 as the positive modulator in the leptin-driven antiobesity in the hypothalamus.